No Surprises Act good faith estimates for the uninsured or self pay applies to occupational therapy practitioners

Effective January 1, 2022, the No Surprises Act includes a provision that requires that a good faith estimate be provided to any patient presenting either with no insurance or choosing not to bill insurance for the visit. In an FAQ, the Centers for Medicare & Medicaid Services (CMS) clarified that this provision applies to all providers in all settings.

The Requirement

The good faith estimate (GFE) must be given to all uninsured patients and patients who have insurance but are electing not to use it for these services. The estimate must also be provided for all other providers that may provide co-treatment. So, if the therapy service is generally rendered as part of post-op recovery from a surgery, the hospital or surgeon may ask you to provide an estimate to them so they may provide the patient with a complete estimate prior to surgery. This request should include a required response date.

Good faith estimates must be given when requested regardless of whether an appointment is scheduled, because the estimate is meant to be used by the consumer as a comparison tool to guide decisions about choosing a health care provider. A notice of the availability of a good faith estimate should be posted both in the office and online. Uninsured patients should also be told verbally of the availability of the GFE. The estimate must be provided in writing, and information regarding the availability of the GFE must be in accessible formats for all patients. 

The GFE must be given to the patient no later than 3 business days after an appointment scheduled more than 10 days in advance. If an appointment is scheduled between 3 and 10 days in advance, the GFE must be given no later than 1 business day after an appointment is scheduled. When requested without an appointment, the response should be no more than 3 business days after the request is made. If changes to the expected services occur, a new GFE must be provided no later than 1 business day before services are rendered. 

The Document

The written GFE requires the following components:

1. Patient name and date of birth
2. Clear description of service and date scheduled (if applicable)
3. List of all items and services (including those to be provided by co-providers)
4. CPT code, diagnosis code, and charge per item of service
5. Name, NPI, and TIN of all service providers and the state where the services will be rendered
6. List of items from other providers that will require separate scheduling
7. Disclaimer that separate GFEs will be issued upon request for services listed in number 6, and that items in number 4 will be provided in those separate GFEs
8. Disclaimer that there may be other services required that must be scheduled separately during the course of treatment and are not included in the GFE
9. Disclaimer that this is only an estimate and actual services, and charges may differ
10. Disclaimer informing the patient of their rights to a patient-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process
11. Disclaimer that GFE is not a contract, and the patient is not required to obtain services from the provider

Patient-Provider Resolution Process

The provided GFE may be used by the patient to initiate a dispute resolution process in the event that billed charges exceed the GFE by $400. The patient has 120 days from receipt of the bill to initiate the dispute process with the Department of Health and Human Services (HHS). The dispute will be reviewed by an HHS-appointed entity. The provider will be allowed to provide documentation to establish medical necessity and/or unforeseen circumstances that could not have been included in the GFE. Parties can settle the dispute and agree upon an acceptable payment amount at any time up until the final decision by the appointed entity. If negotiation is not completed, the resolution entity will provide a final decision based upon the information submitted.

Applicability

While this policy applies to all uninsured patients and patients intending to be self-pay and not bill insurance, we recommend reviewing any insurance contracts in place to see if self-pay requests can be honored. CMS states if at any time insurance is billed, the GFE requirements do not apply. Additionally, because occupational therapy practitioners cannot opt out of Medicare, this requirement would not apply to Medicare patients. The ABN process would continue to apply in instances where services may not be payable by the Medicare program.